City of Columbus, Mississippi
Application for Employment

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Position(s) applied for:

Date of application (mm/dd/yy)

Advertisement Employee Relative

Government Employment Agency Private Employment Agency

Walk-in Other

Name of source (if applicable)

Applicant Information:

Last Name First Name Mid. Int.

Date of Birth (mm/dd/yy)

Address:

Telephone: ( ) -

Mobile/Beeper: ( ) -

Best time to call A.M. P.M.

May we contact you at work Yes No

Work Phone : ( ) -

          If yes, best time to call A.M. P.M.

Are you legally authorized to work in the U.S.? Yes No

If you are under 18, can you submit work permit? Yes No

          If no, please explain:

Have you submitted applications before

Yes No

          If yes, give date(s)

Have you been employed before here Yes No

          If yes, give date(s) From: To:

Date available for work (mm/dd/yy)

Type of employment applying for:

Full-time Part-time Temporary Seasonal Co-op

Are you willing to relocate (if requested)? Yes No

Are you willing to travel (if requested)? Yes No

Are you able to meet the attendance requirements? Yes No

           If no, please explain:

Are you willing to work overtime? Yes No

          If no, please explain:

Have you ever been bonded? Yes No

Have you ever been convicted of a crime ? Yes No

          If yes, please explain:

CONVICTION WILL NOT NECESSARILY BE A BAR TO EMPLOYMENT. EACH INSTANCE AND EXPLANATIO WILLL BE CONSIDERED IN RELATION TO THE POSITION FOR WHICH YOU ARE APPLYING.

Employment History:

Provide the following information for your past and current employers, assignments, or volunteer activities, starting with the most recent. Explain any gaps in employment in the comments section below.

Comments (including explanation of any gaps in employment):

Skills and Qualifications - summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying:

Educational Background
(if job related):

A. List all three (3) schools attended, starting with the most recent;
B. List number of years completed;
C. Indicate degree or diploma earned;
D. Specify Grade Point Average or Class Rank;
E. Major field of study;
F. Minor field of study (if applicable).

References:

List the name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, please list three school or personal references who are not related to you.

Additional Information:

List professional, trade, business, or civic associations and any offices held.
EXCLUDE MEMBERSHIP WHICH WOULD REVEAL SEX, RACE, RELIGION, NATIONAL ORIGIN AGE COLOR, DISABILITY OR ANY OTHER SIMILARLY PROTECTED STATUS.

List special accomplishments, publications, awards, etc.

EXCLUDE MEMBERSHIP WHICH WOULD REVEAL SEX, RACE, RELIGION, NATIONAL ORIGIN AGE COLOR, DISABILITY OR ANY OTHER SIMILARLY PROTECTED STATUS.

List any additional information you would like us to consider:

I UNDERSTAND THAT IF I AM EMPLOYED, ANY MISREPRESENTATION OR MATERIAL OMISSION MADE BY ME ON THIS APPLICATION WILL BE SUFFICIENT CAUSE FOR CANCELLATION OF THIS APPLICATION OR IMMEDIATE DISCHARGE FROM THE EMPLOYER'S SERVICE, WHENEVER IT IS DISCOVERED. I GIVE THE EMPLOYER THE RIGHT TO CONTACT AND OBTAIN INFORMATION FROM ALL REFERENCES, EMPLOYERS, EDUCATIONAL INSTITUTIONS AND TO OTHERWISE VERIFY THE ACCURACY OF THE INFORMATION CONTAINED IN THIS APPLICATION. I HEREBY RELEASE FROM LIABILITY THE EMPLOYER AND IT'S REPRESENTATIVES FOR SEEKING, GATHERING AND USING SUCH INFORMATION AND ALL OTHER PERSONS, CORPORATIONS, OR ORGANIZATIONS FOR FURNISHING SUCH INFORMATION. THE EMPLOYER DOES NOT UNLAWFULLY DISCRIMINATE IN EMPLOYMENT AND NO QUESTION ON THIS APPLICATION IS USED FOR THE PURPOSE OF LIMITING OR EXCUSING ANY APPLICANT FROM CONSIDERATION FOR EMPLOYMENT ON A BASIS PROHIBITED BY LOCAL, STATE OR FEDERAL LAW. THIS APPLICATION WILL REMAIN ACTIVE AND ON FILE FOR THE PERIOD OF ONE (1) YEAR, AT THE CONCLUSION OF THIS TIME, IF I HAVE NOT HEARD FORM THE EMPLOYER AND STILL WISH TO BE CONSIDERED FOR EMPLOYMENT, IT WILL BE NECESSARY TO FILL OUT A NEW APPLICATION. IF I AM HIRED, I UNDERSTAND THAT I AM FREE TO RESIGN AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, AND THE EMPLOYER RESERVES THE SAME RIGHT TO TERMINATE MY EMPLOYMENT AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, EXCEPT AS MAY BE REQUIRED BY LAW. THIS APPLICATION DOES NOT CONSTITUTE AN AGREEMENT OR CONTRACT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OR DEFINITE DURATION. I UNDERSTAND THAT NO REPRESENTATIVE OF THE EMPLOYER, OTHER THAN AN AUTHORIZED OFFICER HAS THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRARY. I FURTHER UNDERSTAND THAT ANY SUCH ASSURANCES MUST BE IN WRITING AND SIGNED BY AN AUTHORIZED OFFICER. I UNDERSTAND IT IS THIS COMPANY'S POLICY NOT TO REFUSE TO HIRE A QUALIFIED INDIVIDUAL WITH A DISABILITYBECAUSE OF THAT PERSON'S NEED FOR A REASONABLE ACCOMMODATION AS REQUIRED BY THE ADA. I ALSO UNDERSTAND THAT IF I AM HIRED, I WILL BE REQUIRED TO PROVIDE PROOF OF IDENTITY AND LEGAL WORK AUTHORIZATION.

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